Gender-Affirmative Therapy for Kids

Q: My client is skeptical about her 15-year-old daughter’s recent coming out as transgender. She’s asking me if it could be rapid onset gender dysphoria (ROGD). How can I advise this parent?

A: Without meaning to, most parents have an image in their minds of what they think their children’s future lives will be like, and when the child reveals something about themselves that shatters that fantasy, it can be scary. I’m a clinical psychologist who’s worked with transgender clients since the 1980s, and I’ve specialized in work with transgender, gender-nonconforming, and nonbinary teens for nearly 15 years. I’ve given a TED talk on this work, and I’m certified as a global provider and mentor by the World Professional Organization for Transgender Health. I’m also a parent, and I’m deeply sympathetic to parents trying to figure out how to respond to a young child who comes out as transgender.

Some parents of transgender children and teens are aware of their child’s gender diversity early on. The daughter who rejects anything remotely girly, for example, or the son who embraces feminine things, exhibit certain gender expressions that often lead parents to think they’re raising a gay child. Sometimes they’re correct, but sometimes it emerges that beyond gender expression, the child has a nontypical gender identity. In other words, the daughter may declare she’s a boy, or nonbinary. Gender identity is our internal sense of our gender, which isn’t obvious to the observer and is often hard for children to describe or express.

It’s not always the case that less common gender expressions lead to less common gender identities. Sometimes, the daughter who comes out as transgender won’t have a history of gender nonconformity, like being a tomboy or rejecting typical girl toys or activities. When a child like this declares themselves transgender, many parents, like your client, disbelieve the child. Even a liberal and open-minded parent, who’d have been able to embrace a gay child fairly easily, might deny the validity of the child’s identity.

As a parent myself, I can understand and empathize with that disbelief. In fact, I could make an argument that a responsible parent would not immediately accept a child’s statement that they are transgender. The implications of supporting your child in a transgender identity are monumental and may include allowing the child to undergo serious, irreversible, hormonal, or surgical treatments. As a parent, you’re making—or allowing—decisions that no minor should have to contemplate, such as medical treatments that could produce lifelong infertility.

Many parents are at least somewhat aware of the medical implications and social difficulties of being transgender, but fewer know about the risks of not supporting a child’s transgender identity. Transgender kids who are rejected or unsupported by their families have extraordinarily high rates of suicide and depression, as well as elevated risk for substance abuse and homelessness. Moreover, denial of early medical treatments, such as puberty blockers, leads to acute gender and body dysphoria. Because blockers prevent the development of unwanted secondary sex characteristics, withholding them alters the appearance of the child forever.

This puts a parent in a near impossible position, particularly the parent of a teenage girl who has no history of gender nonconformity and comes out as transgender seemingly out of the blue. This mother has to choose between putting her child in immediate danger of severe depression or encouraging them to alter their body in ways they may regret later.

Faced with that dilemma, it would be helpful to know what the odds are that the teen is or isn’t truly transgender. Put another way, it would be great to have data on how many kids who transition—live as their affirmed gender, not the gender they were assigned at birth—change their minds later.

Unfortunately, we don’t have that information. Instead, we only have controversial data about younger kids. Some studies, most 20 or 30 years old, suggest that preadolescent children brought to gender identity clinics in Europe and Canada didn’t always turn out to be transgender: a significant number grew up to perhaps be gay, but not trans. Experts in the field debate the methodologies and relevance of those studies. There are also studies from Europe on transgender adults who detransition, reverting to living as the gender they were assigned at birth. These numbers are quite low, about one percent, suggesting that adults who declare a transgender identity are probably secure in their identity.

But we have little follow-up data so far on young people who come out as transgender in adolescence. Short-term data and clinical observations suggest that the identity of trans teens is pretty solid—more so than for younger kids—and doesn’t seem to change, but we don’t know for sure. A couple of large longitudinal studies of transgender children and adolescents are under way, but they’re too recent to yield data from which we can draw useful conclusions.

New vs. Old Models of Treatment

In the United States, the dominant psychotherapeutic model for working with transgender and nonbinary kids and youth is the gender-affirmative model, which I practice. It means that I start with the assumption that the gender identity the child expresses is valid for them in that moment. I make no judgement about the likelihood that the young person will express the same gender identity six months, six years, or six decades from now, but I assume that the identity is important and authentic to that child at this time.

I primarily work with adolescents and not prepubescent kids, and I help them explore their identity: how they got from their birth-assigned gender to the gender they affirm, whether there are other possible causes of their dysphoria, how certain they are themselves, what it means to them to be the gender they affirm, what their birth gender means, and so on. I encourage them to connect with other transgender and queer teens, to read, and to find online and real-world communities. I want them to test out their affirmed identity and be thoughtful about it before I endorse things like hormone replacement therapy.

The gender-affirmative model is relatively new; older forms of treatment focused on trying to get kids to conform to the gender identity and expression they were assigned at birth, which meant denying validation and medical treatment. For decades, mental health practitioners had to “approve” transgender clients for medical care by writing letters certifying necessity, and providers often set an unrealistically high bar for clients, denying medical care to many.

In light of that history, I’ve been accused of gatekeeping—unnecessarily withholding access to medical treatment—by some transgender activists and the occasional client. Some transgender activists believe that interventions such as hormones and surgery should be available without the need for letters from psychiatrists, psychologists, or social workers. I firmly believe in the principle of informed consent for medical procedures for adults, but I also believe that must be modified for minors. As a therapist and parent, I believe adults must guide kids, which means at times restricting their ability to do things that we as their guardians deem too risky.

It shouldn’t surprise us that many parents still struggle with their child’s gender identity. Some therapists are still using older models, including those whose standards the World Professional Association of Transgender Health deem unethical. Parents researching trans identity on their own can find research to support their belief that their children are not really transgender.

In 2018, Lisa Littman, a researcher at Brown University, published a study that described parents reporting that their children were suffering from something Littman called a new disorder, rapid onset gender dysphoria (ROGD). According to the 256 parents Littman surveyed, their children, almost all assigned female at birth, had maintained they were boys during adolescence. These parents reported that many of the adolescents had one or more friends who’d recently come out as transgender, so Littman hypothesized that the adolescents’ claims they were transgender were the manifestation of underlying mental health issues, peer pressure, and the social contagion effect.

In my 30-plus years of working as a clinician with transgender clients, I’ve never seen a case of so-called ROGD. The most important critique of Littman’s study was that not one child was interviewed. ROGD exists in the eyes of the parents, not the youth. We have no indication that the young people, many of whom had transitioned and lived out of the home, regretted their transitions. The parents judged them lost to a cult-like trans community and gender-affirmative therapists, who uncritically accepted their identity and pushed transition. Meanwhile, the ROGD label has been defended by a small but vocal group of millennial and younger detransitioners, who decided to revert to their birth-assigned gender, as well as by therapists who still espouse the old-school method of working with gender-diverse kids.

I understand why it’s tempting to believe a young person is suffering from ROGD. Society at large still stigmatizes transgender people, but in certain liberal enclaves, some kids—and adults—admire peers who come out as trans and even glorify them a bit. In fact, I had an experience with this once a few years ago. Adrienne, a tall, thin 17-year-old, walked into my office and told me that she’d been assigned male at birth but was really female and wanted my help to transition.

She informed me that she hadn’t considered herself transgender until last October, a mere four months earlier. She’d been an isolated, socially immature child, who’d struggled with learning disabilities. She never ”fit in” with other kids, and her gender presentation and interests had been rather androgynous. That September, she’d gone off to a small, arts-oriented, extremely liberal college, which was a haven for queer kids and had a large and visible transgender population. Within weeks, she’d embraced a transgender identity herself. She quickly joined transgender campus groups and for the first time in her life felt that she belonged somewhere.

I could see how a transgender identity could appeal to someone like Adrienne: it explained childhood isolation and feeling different and defective. It offered self-pride and a community of friends and support. In the sheltered atmosphere of her school, she wasn’t exposed to cultural transphobia and was instead welcomed and lauded for her bravery. Much like the parents in Littman’s study, I asked myself if this was a peer-influenced, hastily embraced identity with little foundation, but I never got to find out.

With minors, I spend weeks or months exploring with them how they came to their identity, and I do a careful assessment before recommending medical treatments. Most transgender adolescents want to have those conversations, and they’re able to wait, even if impatiently, for hormone treatments. Adrienne, in contrast, wanted me to write a letter recommending her for hormones on the spot, and when I said no, she fired me for being a gatekeeper. Having met her, I understand why the possibility of ROGD could ring true to some people, but we have no proof that ROGD exists, except in the minds of distraught parents, and the concept garners little professional support.

So What Does Support Mean?

When working with parents wrestling with how to respond to a teen coming out as transgender, you can explain that young people don’t usually acknowledge, even to themselves, that they’re transgender until adolescence, when their bodies start to become unmistakably gendered.

Teens assigned female at birth but self-identifying as male, like your client’s daughter, are increasingly common. Many, but not all, identify as lesbian first in their journeys to sort their feelings out. It’s important for therapists untrained in this area to refer their client to a gender specialist, who will respect the child’s identity while helping the child explore how they have arrived at this identity, what it means to them, and what, if anything, they want to change about their lives.

One of the criteria for a trans identity is that it should be “persistent, consistent, and insistent,” and it takes time to ascertain that. It wouldn’t be helpful for your client, as a parent, to deny her child their feelings and identity, and it could certainly be harmful. Remember that kids who feel supported in their trans identities are happier and less inclined to depression, suicide, and drug or alcohol abuse. But support doesn’t mean you rush to an endocrinologist. It does mean you help your child find an experienced guide, a transgender-affirmative psychotherapist, who can help them untangle the threads of their gender identity. And you can help by facilitating the complicated, emotional journey most parents must make to come to terms with their child’s identity.

Photo © iStock/Motortion